This report should be referenced as follows:Sandall J, Murrells T, Dodwell M, Gibson R, Bewley S, Coxon K, et al. The efficient use of the maternity workforce and the implications for safety and quality in maternity care: a population-based, cross-sectional study. Health Serv Deliv Res 2014;2(38). Health Services and Delivery ResearchISSN 2050-4349 (Print) ISSN 2050-4357 (Online) This journal is a member of and subscribes to the principles of the Committee on Publication Ethics (COPE) (www.publicationethics.org/).Editorial contact: nihredit@southampton.ac.ukThe full HS&DR archive is freely available to view online at www.journalslibrary.nihr.ac.uk/hsdr. Print-on-demand copies can be purchased from the report pages of the NIHR Journals Library website: www.journalslibrary.nihr.ac.uk Criteria for inclusion in the Health Services and Delivery Research journalReports are published in Health Services and Delivery Research (HS&DR) if (1) they have resulted from work for the HS&DR programme or programmes which preceded the HS&DR programme, and (2) they are of a sufficiently high scientific quality as assessed by the reviewers and editors. HS&DR programmeThe Health Services and Delivery Research (HS&DR) programme, part of the National Institute for Health Research (NIHR), was established to fund a broad range of research. It combines the strengths and contributions of two previous NIHR research programmes: the Health Services Research (HSR) programme and the Service Delivery and Organisation (SDO) programme, which were merged in January 2012.The HS&DR programme aims to produce rigorous and relevant evidence on the quality, access and organisation of health services including costs and outcomes, as well as research on implementation. The programme will enhance the strategic focus on research that matters to the NHS and is keen to support ambitious evaluative research to improve health services.For more information about the HS&DR programme please visit the website: http://www.nets.nihr.ac.uk/programmes/hsdr This reportThe research reported in this issue of the journal was funded by the HS&DR programme or one of its proceeding programmes as project number 10/1011/94. The contractual start date was in March 2012. The final report began editorial review in October 2013 and was accepted for publication in March 2014. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors' report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Dep...

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Contracting out of public services, especially ancillary services, has been a key feature of New Public Management since the 1980s. By 2014, more than £100 billion of U.K. public services were being contracted out annually to the private sector. A number of high-profile cases have prompted a debate about the value for money that these contracts provide. Value for money comprises both the cost and the quality of the services. This article empirically tests the contestability and quality shading hypotheses of contracting out in the context of cleaning services in the English National Health Service. Additionally, a new hypothesis of coupling is presented and tested: the effect of contracting of ancillary services on patient health outcomes, using the hospital-acquired infection rate as our measure. Using data from 2010-11 to 2013-14 for 130 National Health Service trusts, the study finds that private providers are cheaper but dirtier than their in-house counterparts. Evidence for Practice • Contracting out of public services, especially auxiliary services, is a key component of New PublicManagement because of the belief that it will lower costs and possibly increase quality. • Economic theory predicts that when quality is hard to measure ex-post or hard to define ex-ante, suppliers may reduce quality to maintain their own costs, as they are the residual claimant on any profit. • We find evidence to support the quality shading hypothesis and the coupling theory. Hospitals contracting out cleaning services had lower levels of cleanliness and worse health-care outcomes as measured by hospitalacquired infections. • Public service managers must be very careful when outsourcing services-even auxiliary services; some performance indicators should reflect aspects of the quality of the core service.

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